Treatment of depression in low-level residential care facilities for the elderly

BACKGROUND

The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).

METHOD

The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.

RESULTS

An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.

CONCLUSION

There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.

A direct functional measure to help ascertain optimal level of residential care

A brieF direct measure oF daily living skills might help place cognitively impaired elders in suitable living environments. In this study, the Test oF Everyday Functional Abilities (TEFA) as a possible adjunctive measure was investigated. The authors recruited 77 cognitively impaired persons in independent living (IL; N = 26), assisted living (AL; N = 25), and dementia special care (SC; N = 26) units. Participants in IL and AL were administered the TEFA and other instruments at baseline and every 6 months over 18 months and when transFerred to a higher level oF care. Special care subjects were administered the same instruments only at baseline. The TEFA clearly separated IL, AL, and SC residents (P < .0001). A TEFA score >50 suggests adequate Functional competence For IL; a score From 30 to 40 adequate Functional competence For AL; and a score oF <30 probable need For an SC unit in the absence oF a capable spouse.

Intraclass correlation coefficients from three cluster randomised controlled trials in primary and residential health care

OBJECTIVE

This paper provides intraclass correlation coefficients (ICCs) for estimation of sample size inflation required in future cluster randomised trials in primary or residential care.

METHODS

Three cluster randomised trials were conducted among middle-aged and older adults in primary care and residential care in Australia and New Zealand between 1995 and 2002. Baseline means or proportions, mean change, and ICCs with their standard errors and 95% confidence intervals are reported for outcome variables used in the three studies. The ICCs were estimated from a one-way random effects model using the analysis of variance method.

RESULTS

ICCs for quality of life and psychological variables in the primary care studies were low (below 0.018). ICCs for clinical and physical activity variables ranged from 0 to 0.08. ICCs for health and functional status in residential care for the elderly were high, ranging from 0.025 to 0.514.

CONCLUSIONS

The magnitude of the intraclass correlation varies with the venue of the trial, the outcome variables used, and the expected effect of the intervention. However, the intraclass correlations provided will be useful for more appropriate planning of residential and primary care-based trials in the future.

Measuring clinical outcomes of animal-assisted therapy: impact on resident medication usage

OBJECTIVE

To measure changes in medication usage of as-needed, psychoactive medications and other select as-needed medication usage as a result of a therapy dog residing in the rehabilitation facility. Additional measures are participants' thoughts and feelings on quality-of-life factors.

DESIGN

One group, pretest, post-test.

SETTING

Residential rehabilitation facility.

PARTICIPANTS

Convenience sample, N = 58 residents living at the facility.

INTERVENTION

A certified, trained therapy dog.

MAIN OUTCOME MEASURE(S)

Changes in as-needed medication usage for the following categories: analgesics, psychoactive medications, and laxatives, as well as changes in vital sign measurements of blood pressure, pulse, respiration rate, and body weight. Additionally, changes in the residents' perception of quality-of-life factors.

RESULTS

One of the three monitored drug classes, analgesia, revealed a decrease in medication usage (mean = 2.6, standard deviation [SD] +/- 6.90, P = 0.017), and one of four monitored vital signs, pulse, showed a decrease (mean = 5.8, SD +/-7.39, P = 0.000) in study participants exposed to the therapy dog. Positive changes were reported in study participants' quality of life.

CONCLUSION

The benefits to human welfare as a result of the presence of a therapy dog have the potential to decrease medication usage for certain conditions in long-term care patients as well as decrease costs. Pharmacist involvement in animal-assisted therapy has the potential to make unique and measurable improvements to best patient care.

Food and Nutrition Care Indicators: Experts’ Views on Quality Indicators for Food and Nutrition Services in Assisted-Living Facilities for Older Adults

This study assessed the views of 153 national experts in nutrition, health, and aging services in assisted-living facilities; including gerontological nutrition (39%), foodservice (14%), aging and disability (22%), geriatric medicine (9%), and assisted living (16%); on the practices that serve as indicators of the quality of food and nutrition services provided in assisted-living facilities and ascertained the most favored style of service delivery: health, amenities, or both. An 88-item Food and Nutrition Care Indicators survey was developed from assisted-living facility regulations in 50 states and other quality indicators of nutrition services. Respondents rated each item on a scale from 1 (not important) to 5 (extremely important). Results show that at least 80% of experts rated the majority of indicators in each domain as highly important (57% of dining room, 67% of foodservice indicators, 65% of general nutrition, and 70% of therapeutic nutrition indicators). Most experts (89%) rated a combination of indicators that included both health (general and therapeutic) and amenities service styles as being highly important. The 57 items rated most important were consolidated into a checklist. A service model that incorporates all of these elements appears to be most appropriate.

New evidence of racial differences in access and their effects on the use of nursing homes among older adults

BACKGROUND

Historical disparities in rates of nursing home placement between blacks and whites have been well documented, and are thought to result from more extensive and supportive social networks, cultural aversion, and poorer geographic access among African Americans. A few recent studies, however, suggest that these racial disparities may no longer exist. We used comprehensive data to assess whether racial differences in nursing home placement remain, and if so, to identify the reasons for them.

METHODS

Data on 6242 black and white self-respondents to the Survey of Assets and Health Dynamics Among the Oldest Old cohort who were 70 years old or older at baseline (1993) were used. Placement status was ascertained at each biennial follow-up through 2004, and discrete-time hazards models were estimated.

RESULTS

After adjusting for baseline covariates, it was found that blacks were 26% (lambda = 0.74, P < 0.001) less likely to use a nursing home over an 11-year period than whites. Moreover, the supply of skilled nursing beds was more salient for nursing home placement for blacks than whites, as was the increasing supply of assisted living beds.

CONCLUSIONS

The racial gap in nursing home placement remains, despite the increased supply of nursing home beds and the emergence of assisted living facilities as the preferred alternative. As the supply of skilled nursing beds increases, in part due to whites choosing assisted living facilities, the racial gap in the risks of nursing home placement may be lessening. Blacks, however, remain less likely to be placed in a nursing home than whites.

A cross-sectional comparison of prevalent diagnoses and medication profiles for residents in an assisted living facility at two time periods

OBJECTIVES

Describe the prevalence of diagnoses and prescribed medications in an assisted living facility for one month in 2001 and 2004.

DESIGN

A descriptive, cross-sectional report.

SETTING

An assisted living facility in Seattle, Washington.

PARTICIPANTS

Assisted living facility residents.

INTERVENTIONS

In March 2001 and January 2004, charts of all the assisted living facility residents were reviewed. Cross-sectional comparisons of demographics, total and average numbers of charted diagnoses, and prescribed medications were conducted. Prevalent diagnoses and medications used were identified. Among the residents present in both periods, longitudinal comparisons of treatment outcomes for hypertension (HTN) and diabetes mellitus (DM) were assessed.

MAIN OUTCOME MEASURES

Changes in demographics, diagnoses, medications, and blood pressure and blood glucose readings.

RESULTS

Charts of 52 (2001) and 54 (2004) residents were reviewed. HTN, DM, and gastrointestinal (GI) disease were the most prevalent diagnoses during both time periods, although the prescribed medications for these conditions were different in 2001 and 2004. The per-resident numbers of diagnoses and medications averaged 7.2 +/- 3.3 and 9.1 +/- 4.7, respectively, in 2004, compared with 5.1 +/- 1.9 and 6.4 +/- 3.6 in 2001. Among 11 residents who lived in the assisted living facility during both data-collection months, the per-resident averages were 5.2 +/- 2.2 diagnoses and 8 +/- 3.9 medications in 2001, compared with 7.9 +/- 2.9 and 11.1 +/- 5.1, respectively, in 2004. The average blood pressure readings among these residents improved in 2004 over those in 2001, though no improvement was seen in the average blood glucose readings.

CONCLUSION

To address the changing needs of assisted living facility residents over time, active ongoing monitoring and assessment of residents' medication therapies by pharmacists are indicated.

Effect of Dementia and Treatment of Dementia on Time to Discharge from Assisted Living Facilities: The Maryland Assisted Living Study

OBJECTIVES

To estimate the association between dementia and time to discharge from individual assisted living (AL) facilities and examine, in residents with dementia, factors associated with shorter duration of residence in individual AL facilities.

DESIGN

Prospective cohort study.

SETTING

Twenty-two AL facilities in central Maryland.

PARTICIPANTS

Stratified random sample of 198 AL residents followed for a median of 18 months.

MEASUREMENTS

Detailed assessments to diagnose dementia; assess treatment of dementia; and rate clinical; cognitive, functional, and quality-of-life measures.

RESULTS

Residents with dementia remained in a facility 209 fewer days at the median (P=.001) than residents without dementia. After adjustment for other variables, lack of treatment for dementia (P=.01) and more-serious medical comorbidity (P=.02) were associated with earlier discharge in participants with dementia. Impaired mobility and limited activity participation had weaker associations with earlier time to discharge.

CONCLUSION

Dementia may accelerate time to discharge, and its treatment may attenuate this effect. The hypothesis that the detection and treatment of dementia might delay discharge from AL should be tested in randomized trials.

Estimated incidence of normal-pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities

Object

The primary objective of this study was to estimate the prevalence of idiopathic normal-pressure hydrocephalus (NPH), both diagnosed and undiagnosed, among residents of assisted-living and extended-care facilities, by using a practical screening tool. A secondary objective was to evaluate prospectively the diagnosis and outcome of surgical treatment in a subset of patients residing in healthcare facilities who were at risk for idiopathic NPH.

Methods

A retrospective chart analysis was performed using the medical records from four nursing homes. The final analysis included 147 patient records. Symptomatology and comorbidity were evaluated, as was the ability to perform activities of daily living. In a subset of 17 patients residing in healthcare facilities, the authors applied a standard idiopathic NPH diagnostic and management protocol and followed up the patients 1 year after treatment.

The estimated incidence of suspected idiopathic NPH among all patients in the retrospective survey ranged from 9 to 14%, depending on the diagnostic criteria used. Among the cohort of 17 patients available for an in-hospital study and 1-year follow up, 11 received shunts and seven of these showed either transient or sustained improvement.

Conclusions

A valid and practical diagnostic method is needed to identify idiopathic NPH accurately before admitting patients to a healthcare facility. Data from a prospective study of 17 patients residing in healthcare facilities indicated that supplementary tests remain predictive of a positive response to shunt insertion but cannot predict whether a favorable outcome will be sustained in a population of patients who have been confined to a wheelchair for a prolonged period of time. This finding supports the notion of a finite window of opportunity for successful treatment of idiopathic NPH and the imperativeness of an early diagnosis.

Improving Assisted Living Care

In the absence of a national measurement system, private vendors of satisfaction measurement and improvement services have played a crucial role in the quality movement in the assisted living industry. Survey responses from 175 resident-family dyads at 20 facilities were analyzed to identify priorities for service improvement from the customers' perspective. They include improving care provided by aides and management, meal service, and activities. Practical solutions for addressing these issues are presented.

The effect of housing on perceptions of quality of life of older adults participating in a medicaid long-term care demonstration project

As the nation struggles with the great increase in the numbers of older adults, many questions arise about how to provide housing and long-term care options that will ensure the quality of life of older adults. This study demonstrates that older adults and their families perceive quality of life more positively once moved from a nursing home to an assisted living facility using Medicaid funds. Results of this exploratory study are promising and suggest that having housing options available across the continuum of care with individualized case management offers older adults the hope for "quality living".

Depression in assisted living is common and related to physical burden

OBJECTIVE

The objective of this study was to obtain a direct estimate of the prevalence of depression, its associated factors, and rates of treatment among residents of assisted living (AL) facilities in central Maryland.

METHOD

One hundred ninety-six AL residents were recruited from 22 (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. Chart review, staff and family history, comprehensive in-person resident evaluation, and the Cornell Scale for Depression in Dementia (CSDD) were administered by an experienced team of geriatric psychiatry clinicians. Those scoring >7 on the CSDD, a cut point repeatedly associated with poor outcomes, were considered clinically depressed.

RESULTS

Participants had an average age of 86 years, most were female and widowed, and 68% met consensus criteria for dementia. Twenty-four percent (47 of 196) of the sample was depressed. In bivariate analyses, depression was significantly related to medical comorbidity, need for activities of daily living (ADLs) assistance, more days spent in bed, and less participation in organized activities. After controlling for pertinent covariates in a regression model, only need for ADL assistance remained significantly associated with depression. Forty-three percent of those currently depressed were receiving antidepressants and were more likely to receive them if they lived in a large AL facility. Sixty percent of depressed residents had no regular source of psychiatric care.

CONCLUSIONS

In the first clinical study implemented by geriatric psychiatry professionals in AL, depression was found to be common, undertreated, and related to physical burden. AL is a rapidly growing segment of long-term care and represents an important setting in which to find and treat serious depression.

The relationship between psychiatric disorders and the ability to age in place in assisted living

OBJECTIVE

Residential care/assisted living (RC/AL) has become a popular long-term care option in the past decade, in part because these settings offer residents a more home-like environment than nursing homes (NHs) while still offering supervision and assistance to meet individuals' personal and healthcare needs. One of the goals of RC/AL is to facilitate residents' ability to age in place by providing access to needed services and thereby delaying NH admission. This article explores individual and facility-level characteristics associated with discharge from RC/AL to NH with particular attention to persons with a psychiatric disorder.

METHODS

A Cox proportional hazards model was used to examine the risk factors associated with discharge from RC/AL to NH for a nonrandom sample of 366 residents in 37 RC/AL facilities in one state.

RESULTS

Thirty-two percent of residents sampled had a psychiatric disorder. Residents with a psychiatric disorder were 1.78 times more likely to discharge to a NH. Other factors significantly associated with discharge from a RC/AL to NH included age (older), being married, more hospitalizations, for-profit ownership status, and part of a NH or continuing care retirement community.

CONCLUSION

This article identifies both facility and individual characteristics that increase the likelihood of RC/AL residents discharging to NHs. Given that one of the main findings is that persons with a psychiatric disorder are at increased risk of discharge to NH, there is a need for improved provision of services for this population in RC/ALs to reduce premature discharge to NHs and to support aging in place in RC/ALs.

Transition to Nursing Home From Assisted Living Is not Associated With Dementia or Dementia-Related Problem Behaviors

OBJECTIVES

To examine risk factors for transition from assisted living (AL) care to skilled nursing facility (SNF) care in a random sample of adults residing in AL.

DESIGN

Baseline clinical evaluation and telephone follow-up at 6-month intervals for up to 36 months.

SETTING

AL facilities in central Maryland.

PARTICIPANTS

There were 198 participants randomly sampled from AL facilities stratified by facility size.

MEASUREMENTS

Consensus diagnoses by multidisciplinary geriatric psychiatry team as well as a broad range of neuropsychiatric and functional scales including Neuropsychiatric Inventory, Cornell Scale for Depression in Dementia, Mini-Mental State Exam, and Alzheimer's Disease Related Quality of Life Scale, as well as cognitive tests. Possible risk factors for transition to SNF were assessed in Cox proportional-hazards multivariate regression methods, using a P value less than .05 for statistical significance.

RESULTS

Twenty-nine participants transitioned to SNF care. Mean AL survival time from baseline evaluation was 0.8 (SD 0.6) years for residents transitioned to SNF and 1.4 (SD 0.7) years for residents remaining in AL at follow-up. Risk factors for transition to SNF included declining health, chronic pain, appetite changes, and being widowed, while insomnia was protective against transition to SNF. Surprisingly, dementia and neuropsychiatric symptoms did not increase risk of transition to SNF.

CONCLUSION

Survival time in AL is determined by factors similar to those operating on community-dwelling elderly, but dementia and neuropsychiatric symptoms do not alter survival time.

Sleep disturbances in the elderly residing in assisted living: findings from the Maryland Assisted Living Study

INTRODUCTION

A majority of the elderly suffer from some sort of sleep disturbance. Common sleep disturbances are insomnia and excessive daytime sleepiness. There are no published studies on the prevalence of sleep disturbance in the assisted living (AL) setting.

OBJECTIVE

To estimate the prevalence, types, and associations of sleep disturbance in a stratified random sample of AL residents, and to explore the effect of sleep disturbance on cognitive and physical functioning, as assessed by the Mini- Mental State Exam (MMSE) and the Psychogeriatric Dependency Rating Scale (PGDRS).

METHODS

Participants were 198 randomly selected assisted living residents in 22 Maryland facilities. Participants were rated on an 11-item sleep questionnaire regarding insomnia and daytime sleepiness.

RESULTS

Sleep disturbance was present in 69% of residents, insomnia (IN) in 42% and excessive daytime sleepiness (DS) in 34.6%. IN and DS scores were not significantly correlated(r = 0.10, p = 0.19). Use of hypnotics, sedating antidepressants, and depression were associated with insomnia. Depression and poor general medical health were associated with daytime sleepiness. On a cognitive task (Mini Mental State Examination) participants with insomnia only out-performed participants with no sleep disturbance and daytime sleepiness; on a measure of physical function (PsychoGeriatric Dependency Rating Scale- physical domain), participants with insomnia fared better than those with daytime sleepiness only and those with both insomnia and daytime sleepiness. Participants with DS only performed worse on both measures compared to those with no sleep disturbance, those with insomnia only, and those with both insomnia and daytime sleepiness.

CONCLUSION

The prevalence of sleep disturbance in AL is similar to that reported in nursing homes. Daytime sleepiness is associated with poorer cognitive and day-to-day functioning, while insomnia is associated with better outcomes. Effective management of DS may lead to improved functioning in the AL residents.

Medicare expenditures for residents in assisted living: data from a national study

OBJECTIVE

To provide preliminary data on Medicare expenditures for assisted living facility (ALF) residents and to investigate whether ALF characteristics were related to Medicare expenditures for ALF residents.

DATA SOURCES/STUDY SETTING

Data from the National Study of Assisted Living for the Frail Elderly conducted in 1998-1999. This analysis was restricted to the 40 percent of ALFs in that sample that adhered to the assisted living (AL) philosophy by offering more than minimal levels of services and privacy. This study involved the approximately 1,200 residents who remained in an ALF from baseline to follow-up data collection. Six months of postbaseline Medicare claims were acquired for 545 of these residents, who did not differ significantly from the larger sample.

DATA COLLECTION

Baseline individual and facility data were collected in personal interviews with residents and a combination of personal and telephone interviews with facility staff. Medicare claims data were acquired from the Centers for Medicare and Medicaid Services.

STUDY DESIGN

Cross-sectional analyses using logistic and ordinary least squares regression techniques were used to determine the relationships among individual and facility characteristics and Medicare utilization and expenditures.

PRINCIPAL FINDINGS

On an annualized basis, AL residents incurred Medicare costs of approximately US dollars 4,800. Just less than 15 percent of AL residents accounted for over 75 percent of total Medicare costs. Both the likelihood of utilizing Medicare-covered services and the intensity of service use were largely unaffected by the characteristics of the ALF in which residents lived. Utilization was largely a function of individual characteristics. The only exception to this general finding was that those individuals who utilized services and resided in smaller ALFs had significantly lower average expenditures than did individuals in larger ALFs.

CONCLUSIONS

These preliminary data imply that both the level and distribution of Medicare expenditures among ALF residents were similar to those among the general community-dwelling Medicare beneficiary population. No significant relationships were observed between ALF characteristics and Medicare expenditures, except the effect of facility size. This result may imply that how the AL industry eventually defines itself in terms of services and amenities, other than size, may have little impact on Medicare expenditures for ALF residents. However, this is a single, initial study, so caution must be exercised when considering the implications of these results.

[Nursing needs among recipients of community health care]

BACKGROUND

We aimed at investigating whether disabled old people can get sufficient care in residential facilities for the elderly.

MATERIALS AND METHODS

All residents in our community's care facilities for the elderly in 2001 were registered. Those living in their own homes with a substantial need for care were also registered. Burden of care was assessed by six items measuring activities of daily life and two items measuring cognitive decline.

RESULTS

309 persons were registered; mean age was 84. Those living in residential care facilities staffed 24 hours a day represented the highest average burden of care, though many elderly living in their own homes also need a great deal of care. In our community, the number of nursing home beds set aside for short-term stays has decreased from 24 to 11 over a eight-year period. The burden of care has increased since 1992 in nursing homes as well as in other residential care units.

INTERPRETATION

Group-dwelling unit staffed around the clock can be a good alternative to nursing homes for many demented patients. While a high number of such units have been built, the local authorities have found it increasingly difficult to provide a sufficient number of nursing home beds for short-term stays. Most changes observed can be related to the growing number of inhabitants above 80 years of age.

Admissions to skilled nursing facilities from assisted living facilities

Minimum Data Set data from 15,977 residents were analyzed to investigate the reasons older adults were admitted to skilled nursing facilities from assisted living facilities. Residents admitted from assisted living facilities, private homes, hospitals, and hospitals with previous assisted living facility residence were compared. Findings suggest that residents admitted from assisted living facilities are more likely to be older, to have diagnoses of dementia and depression, and to be placed in Alzheimer's special care units.

Influence of cognitive impairment, functional impairment and care setting on dementia care mapping results

Quality of life (QOL) for people with dementia has become a major focus over the past decade. Dementia care mapping (DCM) is an observational measure of quality of care given by staff in formal care settings, as well as a measure of QOL that has been used in many studies of people with dementia in residential care settings. However, the method itself has not been rigorously studied in a scientific manner. For this report, mapping data were collected for 166 persons with dementia in three types of care settings: special care facilities that are licensed nursing homes, assisted living facilities, and adult day centers. The relationships between DCM and several independent variables including cognitive status, functional status, care setting, depression, length of stay, and co-morbid illnesses were assessed. Both cognitive status and functional status were found to be associated with DCM scores. Moreover, DCM was sensitive in differentiating among persons with four levels of cognitive impairment. Implications for practice are discussed.

Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management

OBJECTIVES

To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

DESIGN

Cross-sectional study.

SETTINGS

A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).

PARTICIPANTS

A total of 2,078 RC/AL residents aged 65 and older.

MEASUREMENT

Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.

RESULTS

Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).

CONCLUSION

Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.